Hospital Transfer of Neuro-trauma Patients Increases Survival Rate

Photo_BekelisGuest post from Kimon Bekelis, MD
Section of Neurosurgery, Dartmouth-Hitchcock Medical Center

Value reigns supreme in the world of healthcare delivery today. Value has been defined easily as:

COST/QUALITY 

A recent landmark study tackles the difficult question on the value of expensive helicopter transport in the care of traumatic brain injury (TBI) patients. To fully appreciate the results of this work, it is necessary to grasp the scope of TBI in the U.S. today.

  • TBI contributes to a substantial number of deaths and cases of permanent disability in the U.S.;
  • 1.7 million TBIs occur annually;
  • Estimated direct medical costs is $31.7 billion;
  • Estimated global cost is $48.3 billion; and
  • Often impact during prime years (ages 16-30).

Significant improvements in survival for this patient population have been achieved through widespread use of evidence-based guidelines, centralization of care and advances in neurocritical care. Other important factors — which allow patients to capitalize on the aforementioned developments — are improvements in emergency medical services (EMS) and timely transport to specialized trauma centers, capable of providing life-saving interventions.

Frontal cerebral contusions secondary to a motor vehicle accident

Frontal cerebral contusions secondary to a motor vehicle accident

Within this setting, helicopter utilization and its value — based on the effect on outcomes of TBI — remains a hotly debated issue. Helicopter transport is one of the most expensive interventions in modern emergency medicine, with annual cost ranging from $114,777 to $4.5 million per institution. Other studies have suggested there is no value in using helicopter transport for patient with TBI. However, all of these studies had limited generalizability given their focus on single center or regional analyses.

A historic study recently published in the Annals of Surgery1 has demonstrated that helicopter transport is associated with increased survival (Table 1) in comparison to ground EMS — using the National Trauma Data Bank, the largest trauma registry in the country. The analysis was based on national level data, and addressed methodologic limitations of prior studies, controlling for confounders (including the neurologic status and injury severity of the patient), and producing robust results through several analytic iterations, including a propensity score matched cohort.

Table 1. Models demonstrating the association of helicopter transport with survival of TBI patients

OR (95% CI) P-value ARR, % (95% CI)
Level I Trauma Centers      
  Logistic regression      
  Standard 1.95 (1.81-2.10) <0.001 6.37 (5.89-6.85)
  Incorporating propensity score matching 1.88 (1.74-2.03) <0.001 5.93 (5.46-6.40)
Level II Trauma Centers      
  Logistic regression      
  Standard 1.81 (1.64-2.00) <0.001 5.17 (4.55-5.79)
  Incorporating propensity score matching 1.73 (1.55-1.94) <0.001 4.69 (4.08-5.31)

Abbreviations: OR: Odds Ratio, ARR: Absolute Risk Reduction

For all trauma patients, in order to save one life you would need to transport 65 patients with a helicopter.2 The present study1 revealed this effect is more pronounced for patients with TBI, with only 17 patients needed transport to save one life. A recent analysis3 concluded that helicopter transport needs to provide a minimum of 17 percent relative reduction in mortality (1.6 lives saved every 100 patients) to be cost-effective. These data are compatible with the number of TBI patients which needed transport in order to save one life, supporting the cost effectiveness of helicopter transport for this population.

Patients with TBI are some of the most severely injured trauma patients, in need of timely, efficient and specialized care. The value equation for care delivery requires both cost and quality be optimized. Recent evidence allows patients to be first priority, through use of helicopter utilization to improve access of this population in specialized trauma centers. To this end, the impact helicopter transport has to increase survival rates among neuro-trauma patients should be taken into account by policy makers and payors.

References

1. K. Bekelis, S. Missios, T.A. MacKenzie. Pre-hospital helicopter transportation and survival of patients with traumatic brain injury. Annals of Surgery, 2015 Mar;261(3):579-85

2. Galvagno SMJ, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA 2012; 307(15):1602-1610

3. Delgado MK, Staudenmayer KL, Wang NE, et al. Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States. Ann Emerg Med 2013;63(4):411.

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Neurosurgeons are NOT Just Brain Surgeons

Most people think neurosurgeons are only brain surgeons, but that is far from the truth. Since August is Neurosurgery Awareness Month, we wanted to take a moment to highlight the breadth of neurosurgical practice. Featured below is an animation we developed demonstrating that neurosurgery is indeed more than just brain surgery! We encourage everyone to join the conversation online by using the hashtag #neurosurgerymonth.

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Resident Reflection: Holding the Line against Apathy

headshot for CompassionGuest post from Ahilan Sivaganesan, MD
Neurosurgery Resident Physician, Vanderbilt University Medical Center

The vast majority of physicians enter medicine with an inborn sense of compassion. Junior residents, however, are the logistical workhorses of teaching hospitals — their north star is efficiency and they are measured largely on their capacity to “get things done.” The consequence is often a slide towards unwitting apathy. I, like all residents, have witnessed this reality first-hand. By reflecting on my experiences, I hope to discover insights we can all use to take matters into our own hands.

Clinical Anecdote

The message reached my pager at 3:30 p.m. on a frigid, unforgiving December day: “31 year old male, motor vehicle crash, no movement arms/legs.” Bringing myself to within an inch of the man’s face I bellowed: “Sir, open your eyes!” No response. As clinically indicated, I then made a fist with my right hand and performed a sternal rub, digging my knuckles into his sternum with gritted teeth. Still no response. Then suddenly, the man spontaneously opened his eyes, looked frantically around the room, and then closed his eyes again.

Exasperated, I wondered, “What’s going on here?” Suddenly it hit me. I reviewed the patient’s scans and my fear was confirmed. Cervical spine injury and brainstem hemorrhage had rendered the patient “locked in.” Although fully alert, he was paralyzed from the neck down. Roving eyes were the only proof that a man still lived inside his lifeless body. He would be a prisoner unto himself. Fighting my instinct to stop and take stock of this tragedy with the man’s family, I rushed away to make preparations for surgery. Commiseration would have to wait.

The memory of this patient remains a splinter in my mind. The devastation — of a man’s life, of a family’s future — had passed by me that day as a mental footnote. I had fulfilled my obligations as a neurosurgery resident, but was there space for my full humanity?

A Resident’s View

“Doctor, Mrs. Anderson is in serious pain after surgery. She has morphine ordered, but it’s not cutting it.”

“Doctor, Mr. Johnson is asking to stay another day. He’s been discharged, but he doesn’t have a ride.”

resDuring medical school, I would have pounced on these scenarios as opportunities for genuine doctoring. As a resident, however, they have become issues that need to be “handled” — new tasks for my to-do list. A patient’s inadequately controlled pain, then, is not the gnawing discomfort of a 40-year old mother of two, but rather a new un-checked box on my to-do list. A grandfather stranded in the hospital, with no transportation, means I have to keep an extra patient on our list.

How do I combat this plague of unwitting apathy? I start with mindfulness. Before entering any patient’s room I take a deep breath, mentally set aside all other looming tasks, and resolve to treat the interaction as an opportunity for true connection. It is a matter of being deliberate. I try to leave every interaction having learned at least one unique, personal fact — a reminder that a patient is not just a vessel for surgical pathology. What if the ubiquitous “patient list,” which all residents carry, were to incorporate these humanizing facts? Suddenly, bed 10 is no longer a “50yo M, post-op day 5 from aneurysm clipping,” he is a “50yo M with a son in Afghanistan who is post-op day 5 from aneurysm clipping.” Solutions such as this, which imbue our workflows with the fruits of rich patient interaction, may buffet a slide toward apathy. A system of credits, wherein patients can register their gratitude for caring residents, may also make a difference.

Ultimately, we must discern the various elements of a vibrant doctor-patient connection, and then weave triggers for those elements into residents’ daily activities. I will always remember walking into that spine-injured patient’s room the day after his surgery and noticing his college graduation photo pinned to the ICU monitor. Looking back and forth from his mangled face to the photo, I slowly realized that they were the same person. From that moment, that image — of a healthy, proud young man — was what came to mind whenever I thought of him. I began to see him the way his loved ones saw him, and I’m sure I provided more compassionate care because of it.

Is that not the standard to which we must aspire — to treat patients as if they were our loved ones? There is much a resident can be cynical about in healthcare. Much is out of our control. But how we relate to patients is a personal choice, and physicians can take simple steps to sustain the inborn compassion that drove them to medicine in the first place.

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